When Devin Miller, leader of the abortion rights group Medical Students for Choice at Virginia Commonwealth University, heard about the slaying of George Tiller, a Kansas physician who performed late abortions, she "took a step back" to ponder her future. The second-year student plans to become an obstetrician-gynecologist or family physician and expects she would sometimes terminate pregnancies. But the May 31 death of Tiller, who was shot in the head at church, allegedly by an antiabortion activist, has left the 23-year-old deeply shaken.

"I think for a lot of students right now, it's very hard to be confronted with the constant negative energy and constant fighting" that surrounds abortion, said Miller, who grew up in a southern Virginia city where antiabortion sentiment runs high. Just learning about the procedure at the state school in Richmond can be a challenge. Medical students who want training in the procedure usually must arrange an elective "externship" in Northern Virginia, she said.

Thirty-six years after it was legalized, abortion remains one of the most common procedures in American medicine -- and the most stigmatized. In 2005, 1.2 million abortions were performed, dwarfing the number of appendectomies (341,000), gallbladder removals (398,000) and hysterectomies (575,000). "There's this feeling it's dirty and should not be spoken about," said Miller. "It's hard to be brave and seek everything out yourself."

Her soul-searching underscores a long-standing problem some reproductive health experts say is worsening: a shortage of physicians willing to perform abortions. Although nearly one-third of American women will have an abortion by age 45, according to the Guttmacher Institute, a respected New York research organization, the number of abortion providers dropped from 2,908 in 1982 to 1,787 in 2005. Eighty-seven percent of counties in the United States and 31 percent of metropolitan areas have no abortion services.

Even before Tiller's death, and before abortion became entangled in the rancorous debate about health-care reform (antiabortion groups say it will expand abortion, a claim reform advocates say is false), the American College of Obstetricians and Gynecologists warned that "the availability of abortion services is in jeopardy."

In a January report, an ACOG committee found that one-third of American medical schools provide a formal lecture about abortion. Unlike most clinical experiences, which are integrated into the curriculum, abortion training is often optional, leaving time-starved trainees to learn about the procedure on their own. Medical school administrators contacted for this story declined to discuss abortion education.

In 1996, concerned about the lack of training in OB-GYN residencies, the Accreditation Council for Graduate Medical Education required that "induced abortion must be part of residency training" but allowed residents or programs with moral or religious objections to opt out; all residents must learn how to manage abortion complications. A 2008 study found that among OB-GYN residents who said they wanted to provide abortions once they started practicing, about half actually did.

"Our doctors are graying and are not being replaced," said Susan Hill, president of the National Women's Health Foundation in Raleigh, N.C., which operates abortion clinics in largely rural states, including Georgia, Indiana and Mississippi, where only one doctor in the state performs pregnancy terminations.

"We need young doctors and we need them badly," said Hill, whose clinics have been firebombed or set ablaze 18 times. "The situation is pretty grave, pretty dire."

A report in the journal Contraception last year found that 66 percent of physicians performing second-trimester abortions are more than 50 years old. Unlike their younger counterparts, many older doctors cite searing memories of days before the procedure was legal, when they cared for women who tried to perform abortions on themselves using lye or coat hangers.

Scaring Young Doctors

The shortage of doctors willing to perform abortions "has huge public health implications," said Lois Backus, executive director of the Philadelphia-based Medical Students for Choice, founded in 1993 after the murder of a Florida doctor -- the first of eight people killed in clinic-related violence in the past 16 years. Because about half of pregnancies are unintended, most doctors will at some point treat women confronting a choice about pregnancy, Backus said.

Although such care was once common, few physicians currently offer abortion services in their offices, fearing they will be targeted by abortion foes. Instead, Backus said, many tell patients facing unwanted pregnancy to look in the Yellow Pages or call Planned Parenthood.